Cardiovascular Fellowship Curriculum
Clinical and Research Cardiac Electrophysiology Program
List of Faculty:
Raveen Bazaz, MD
William Barrington, MD
Susan Brode, MD
Sandeep K. Jain, MD
Ogundu Ngwu, MD
Samir Saba, MD
Soraya Samii, MD, PhD
David Schwartzman, MD
Goals and Objectives
Educational purpose and rationale for training the clinical cardiac electrophysiology specialist
The primary objective of the advanced training program in Clinical Cardiac Electrophysiology is to provide
level III training for the individual who has completed a 3-year cardiology fellowship and wishes to
specialize in invasive, diagnostic and therapeutic cardiac electrophysiology. Because of the tremendous
advances in cardiac electyrophysiology, the fellowship has now been extended to two years, one in basic
or clinical research and one year in clinical electrophysiology.
The primary goals of this training are to develop and enhance the trainees skills: 1) in the
technical/procedural aspects of clinical electrophysiology with special emphasis on the steps leading to
the appropriate choice of procedure including the indications, contraindications, risks and benefit of each
alternative; 2) in communicating findings and diagnostic/therapeutic plans to the patient and family as
well as the patient’s primary care physician; 3) in leadership and teaching of residents and cardiology
fellows that are otherwise caring for the patient or rotating through the electrophysiology rotation.
The expectation is that the trainee’s involvement in the pre-procedure, procedural and post-procedural
periods of patient care will provide them with a longitudinal experience in the application of clinical
cardiac electrophysiology.
Methodology of Teaching Goals and Objectives
Principal teaching method
The principal method for teaching clinical cardiac electrophysiology utilizes a “one-on-one” interaction
between the trainee and the individual faculty attending. The attending faculty serves as a role model for
the trainee particularly in terms of professionalism and the interpersonal and communication skills
needed to deal with patients, their families, other physicians and ancillary support services. The analytic
and procedural skills required to perform clinical cardiac electrophysiology will be developed by initially
having the attending faculty demonstrate these skills to the individual trainee. As the trainee’s skill and
knowledge in clinical electrophysiology increases, they will assume an ever increasing role in performing
the analysis and procedures (under the direct supervision of the attending physician) ultimately becoming
the primary operator. This constant faculty interaction will allow the trainee to critically evaluate their own
analytic processes and patient care by comparison to more experienced electrophysiologists.
The “one-on-one” teaching experience is supplemented by the daily “EP morning report” that allows the
clinical faculty, nursing staff, general cardiology and advanced electrophysiology fellows to review and
discuss the patients that are: 1) currently on the inpatient EP service; 2) scheduled for procedures that
day; 3) or have some interesting clinical feature. This setting provides an opportunity for all the trainees
to learn the issues involved in developing a clinical plan for each of the patients, even if the trainee has
not been directly involved in that patient’s care. Additionally, interesting cases, ECG’s or tracings are
presented to the group to allow input from all of the parties. These discussions often bring forth different
approaches to a problem frequently highlighting new information and techniques that can be applied to
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the problem at hand. In this manner, the faculty serves as a role model of system based practice and
demonstrate for the trainees a practice that utilizes system based learning for improvement in clinical
care.
Educational Content
Mix of Disease
Approximately 60% of patients seen by the cardiac electrophysiology service are referred for evaluation
of ventricular arrhythmias, 30% for evaluation of superventricular arrhythmias with the remainder referred
for evaluation of syncope, palpitations or an abnormal electrocardiogram. The majority (60%) of patients
have atherosclerotic coronary disease or a cardiomyopathy, while 30% have a structurally normal heart.
The remainder have a variety of abnormalities including hypertensive or valvular heart disease as well as
corrected (or uncorrected) congenital heart disease such as the Tetrology of Fallot.
Patient Characteristics
The patients seen by the University of Pittsburgh Medical Center Electrophysiology Service reflect the
demographics and spectrum of heart disease seen in Pittsburgh. The majority of the patients (~60%) are
60 years of age or older and are being evaluated for ventricular arrhythmias, conduction disease, atrial
fibrillation or risk stratification following myocardial infarction. The remaining patients are under the age of
60 and will largely have supraventricular arrhythmias, syncope, non-ischemic or congenital heart disease.
The majority of these patients will be male (~60%) with an approximately 50% split between in-patients
and out-patient/same day procedures.
Environment of teaching
The teaching environment for the advanced cardiac electrophysiology fellowship includes two state-ofthe-art cardiac electrophysiology laboratories both of which are equipped with biplane cine-angiography
capabilities, computerized mapping systems and digital display/stimulator systems. These laboratories
have the capabilities of performing the entire range of invasive cardiac electrophysiology procedures
including diagnostic EP studies, complex ablations and device implantation.
An additional laboratory for device implantation and a minor procedure room that allows the performance
of non-invasive programmed stimulation, tilt table testing and elective cardioversion procedures,
supplement these facilities.
Consultative services are provided on the inpatient wards and intensive care units at PresbyterianUniversity and Montefiore Hospitals as well as in the outpatient/clinic facilities on floor 5B at
Presbyterian-University Hospital.
Procedures and Services
The full spectrum of diagnostic, interventional and therapeutic electrophysiology procedures are
performed in the UPMC Electrophysiology Laboratories. During the advanced electrophysiology
fellowship the trainee will have the opportunity to perform at least 200 invasive electrophysiologic
procedures, approximately half of which will be for the evaluation of supraventricular arrhythmias. At
times, these procedures will be utilized for strictly diagnostic purposes but, most commonly, they will
serve to guide further therapy. Frequently, these procedures will provide the information necessary to
perform catheter ablation and it is expected that the trainee will be involved in at least 75 radiofrequency
ablation procedures during their training. The ablation procedures will involve a variety of arrhythmias
including atrial tachycardias, tachyarrhythmias associated with the Wolf-Parkinson-White syndrome, atrial
flutter, atrial fibrillation, AV node re-entry, and various ventricular tachycardias that are seen in both the
normal and abnormal heart. In other situations, the electrophysiologic results will not be amenable to
ablative therapy and will subsequently require placement of a pacemaker, defibrillator or cardiac
resynchronization device. During the fellowship year the trainee will be involved in at least 75 pacemaker
implantations/revision procedures and at least 50 defibrillator implantations/revision procedures.
Additionally, with the increasing use of cardiac resynchronization therapy, the trainee can also expect to
be involved in the performance of at least 25 of these procedures during their year of training. All of this
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meets or exceeds the American College of Cardiology recommendations for Level III training in cardiac
electrophysiology.
While the technical skills of these invasive procedures are important, the trainee will also have extensive
exposure to the non-invasive evaluation and follow up of implantable devices including at least 100
pacemaker follow up visits, at least 75 defibrillator follow up visits and at least 50 evaluation of devices
that provide cardiac resynchronization therapy. Additionally they will acquire experience in the noninvasive testing of these devices on both an inpatient and outpatient basis.
Pathological and Other Resources
The pathology, radiology and laboratory services are fully supportive of the cardiovascular
electrophysiology service. This involves pathology review of biopsy specimens as well gross specimens
at autopsy. Complete radiological and laboratory services are also available with web based access to all
laboratory, radiological and pathologic reports available though out the hospital.
Educational Materials
All the current standard cardiology texts are available in the fellows library along with selected cardiology
journals and computers that allow access to Web-based medical information sources such as “up-todate.”
Suggested Readings
The recommended text for the clinical cardiac electrophysiology trainee is Clinical Cardiac
Electrophysiology Techniques and Interpretations third edition by Mark Josephson, M.D. copyright 2002
by Lippincott, Williams and Wilkins. Supplemental electrophysiology texts include Cardiac
Electrophysiology from Cell to Bedside by Zipes and Jalife published by William Saunders Company and
Interventional Electrophysiology second edition by Igor Singer published by Lippincott, Williams and
Wilkins.
Frequently, specific questions will arise that are best addressed with selected articles from cardiology or
electrophysiology specific journals. These may be recommended by the faculty – or found during a
literature survey conducted by the trainee. In any event, many of these references are available in the
University of Pittsburgh Medical library or various Web-based sources.
Formal Conferences
Two electrophysiology specific conferences are included in the cardiac electrophysiology curriculum: 1)
didactic lectures that are integrated into the cardiology lecture series covering a variety of
electrophysiology topics including cellular electrophysiology, techniques of device implantation,
comparison of pacing modalities etc…all of which are given by the electrophysiology faculty and; 2)
“journal club” that looks at a topic of the trainees choice. These articles are typically chosen based on a
recent case or pertinent clinical question and are directed/presented by the trainee with the other trainees
and EP faculty/staff in attendance.
Method of Fellow Evaluation
The “one-on-one” teaching method employed on the cardiac electrophysiology service leads to frequent
verbal feedback/evaluation of the trainee’s progress in every aspect of their electrophysiology training.
This frequent interaction allows the faculty the opportunity to observe not only the trainee’s procedural
skills, but also their professionalism, interpersonal and communication skills. These observations will
provide the basis for the formal written evaluation completed by the faculty at the end of each rotation.
This evaluation is provided for the trainee’s review so that he may sign it if he concurs with the
assessment or discuss any disagreement with the faculty at that time.
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Responsibilities of the Electrophysiology Fellows
The cardiac electrophysiology fellow is responsible for the evaluation and treatment of the
electrophysiology patients in collaboration with the attending faculty. They must be available throughout
the working day by pager and must notify the Program Director and supervising faculty if they are
unexpectedly required to be absent.
All electrophysiology fellows are expected to attend and participate in the daily EP morning report that
begins at 8AM Monday through Friday. This means the trainee should be prepared to discuss any
patients they performed procedures on the prior day as well as any patient they plan to perform
procedures on that day. This will provide the trainee with experience in the continuum of patient care by
allowing them to assess the effectiveness of their care, hone their interpersonal/communication skills and
develop a sense of the normal course of various types of cardiac electrophysiology disease.
It is expected that the electrophysiology trainee will interview/examine the inpatients the night before the
procedure, performing an appropriate history/physical with review of the records and formulation of a plan
that can be presented at EP morning report. In the case of outpatients, a similar evaluation may be
performed when the patient arrives in the outpatient area on 6G.
The electrophysiology trainee will then be involved in performing the procedure, with increasing degrees
of involvement as their experience and skill grows. They will be expected to check on the patients they
performed procedures on – before leaving for the day and will be available during the regular workday to
address any concerns that may arise during the post procedure period. If the patient received an
implanted device, the fellow will be expected to evaluate the post-operative chest x-ray and perform the
pre-discharge device evaluation the following morning.
When the electrophysiology fellow is assigned to the consultative service, they will be responsible for the
organization of the EP consultation service with attention towards a fair distribution of patients between
the other rotating cardiology fellows and appropriate prioritization of patients in terms of the immediacy of
consultation and the need for an EP procedure.
The objectives for each of the clinical rotations will also be provided for the trainee at the beginning of the
12-month fellowship and will be reviewed at the beginning of each rotation.
Duty Hours
The duty hours for the cardiac electrophysiology fellow conform to the guidelines issued by the Graduate
Medical Education committee of the University of Pittsburgh and have the same restrictions regarding
work or “moonlighting” outside of the electrophysiology training program. The Cardiac Electrophysiology
fellow does not have any over night or in house call responsibilities. One weekend call can be expected
each month with the duty consisting of rounding on the inpatient service and seeing new consultations
with the attending staff both Saturday and Sunday morning. The fellow is not responsible for any over
night call duties on Friday, Saturday or Sunday night. This schedule also applies to University holidays.
Procedure Logs
Each electrophysiology trainee is responsible for maintaining a log of supervised procedures. The format
of this log should conform to the procedure log contained in the UPMC Fellowship in Cardiovascular
Disease program manual and should contain at a minimum entries for Patient, Date, Procedure Type,
Indications, Diagnosis, Complications and Supervisor Signature. Copies of this log should be provided to
the Electrophysiology Training Program Director every quarter for inclusion in the trainee’s file. If these
logs are not provided, it will be impossible for the Program Director to certify that the trainee has fulfilled
the requirements of the Electrophysiology Fellowship.
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Expected Electrophysiology Fellow Accomplishments
Following the successful completion of this fellowship, the trainee will have achieved level III training in
Clinical Cardiac Electrophysiology with a wide range of experience as a consultant in arrhythmia
management with the invasive skills to perform electrophysiology studies, catheter ablations and implant
pacers, defibrillators and cardiac resynchronization devices.
June 2005
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